- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.12 / $158.29 / $174.73
| Professional | | $107.12 | $158.29 | $174.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.54 / $182.05 / $259.22
| Professional | | $141.54 | $182.05 | $259.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.05 / $209.93 / $350.35
| Professional | | $168.05 | $209.93 | $350.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.85 / $228.22 / $339.71
| Professional | | $149.85 | $228.22 | $339.71 |